INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, MVP Recovery LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of two personnel record reviewed.Employee #3 was hired as a counselor on January 6, 2025. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than January 6, 2026. The HIV/AIDS training was completed; however, there was no documentation provided indicating the completion of the TB/STD training as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nursing staff will develop training on HIV/AIDS and TB/STD that comply with DDAP training requirements by 5/30/26. All new employees will complete these training courses within their first 30 days of employment. All current staff members who have not received these trainings will complete the training by 6/30/26. The Program Director will ensure training compliance through monthly training reviews during staff supervision. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's March 2025 through February 2026 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts. The facility's posted hours of operation are Monday through Friday 8:00AM - 8:00PM. All the fire drills conducted, during the reviewed period, were completed prior to or at 4:00PM. There were no fire drills conducted during the evening hours of operation. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility supervisor will designate one day per month to conduct a fire drill. Drills will be conducted on a rotating schedule, with one occurring during evening hours every other month and one during daytime hours on alternating months to ensure coverage across shifts. The on-site supervisor will ensure that drills are conducted when both staff and clients are present to promote effective participation and preparedness |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records, the facility failed to maintain the confidentiality of client identity and records by not following procedures pertaining to how the project plans to address the security and release of electronic records.During the client record review, there was documentation pertaining to another client filed within client #2's record.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All incoming and transferred charts will be reviewed by the site supervisor to ensure completeness and compliance. Clinical documentation will be reviewed by clinical staff upon transfer, and staff will submit a completion form to the supervisor for final verification. Clinical staff will establish and maintain organized folders designated for each client and their corresponding documentation. Monthly chart audits will be conducted by the supervisor during supervision sessions. During each audit, the supervisor will randomly select three charts and complete a comprehensive review of all documentation within each chart to ensure accuracy, completeness, and adherence to standards. |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on a consent to release information form in one of seven client records reviewed. Client #5 was admitted on September 18, 2025 and was discharged on December 16, 2025. There was a release of information form to an external individual signed and dated by the client on September 18, 2025; however, there was no purpose of the disclosure included on the release form.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received re-education on 4/27/2026 the Release of Information (ROI) process, including proper manual completion procedures, specifically emphasizing the completion of the purpose of disclosure. Moving forward, daily chart audits will be conducted by the program director to ensure all Releases of Information are completed accurately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure a copy of a client consent to release information form was offered to the client in two of seven client records reviewed.Client #5 was admitted on September 18, 2025 and was discharged on December 16, 2025. There was a release of information form to an external individual signed and dated by the client on September 18, 2025; however, there was no documentation in the record indicating a copy of the consent form was offered to the client.Client #6 was admitted on December 19, 2025 and was discharged on February 19, 2026. There were release of information forms to an external individual and to a funding source that were signed and dated by the client on October 24, 2025; however, there was no documentation in the record indicating a copy of either consent form was offered to the client.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Staff received re-education on 4/27/2026 the Release of Information (ROI) process, including proper manual completion procedures, specifically emphasizing offering the client a copy of their consent form. Moving forward, daily chart audits will be conducted by the program director to ensure all Releases of Information are completed accurately. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of client records and discussions with project staff, the project failed to maintain a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.The facility's policy and procedures stated all client records shall be maintained in a secure electronic medical record (EMR) system, and the policy applies to all client records created and maintained by the behavioral health providers and administrative staff, including clinical notes, assessments, treatment plans, progress notes, billing documentation and correspondence. At the time of the inspection, the facility does not keep paper client records and maintains an electronic record system. All paper documentation is to be scanned into the electronic record by the staff in a timely fashion. During the client record review, most of the client initial, comprehensive, and updated treatment plans were uploaded/linked to the electronic medical record within a few days of this inspection's start date. The treatment plans reviewed during the inspection were completed in 2025 and the staff were not following facility policy.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
As of 4/23/2026, all staff have been retrained on the timely uploading of all paper documents into each client's electronic medical record. Training emphasized the importance of prompt documentation and reviewed required timeframes for uploading all records, with specific focus on treatment plans. Staff were re-educated that completed treatment plans must be uploaded to the client's EMR within 24 hours of completion.
To ensure ongoing compliance, the supervisor will conduct monthly chart audits to verify that the complete client record, including all paper documentation, is accurately uploaded and accessible within the client's electronic medical record. |